The Egyptian Journal of Radiology and Nuclear Medicine (2014) xxx, xxx–xxx

ARTICLE IN PRESS

Egyptian Society of Radiology and Nuclear Medicine

The Egyptian Journal of Radiology andNuclearMedicine

www.elsevier.com/locate/ejrnmwww.sciencedirect.com

ORIGINAL ARTICLE

Comparative study between breast tomosynthesis

and classic digital mammography in the evaluation

of different breast lesions

* Corresponding author at: Kasr ElAiny Hospital, Cairo University, Egypt. Tel.: +20 1006029047.

E-mail address: sahar_mnsr@yahoo.com (S. Mansour).

Peer review under responsibility of Egyptian Society of Radiology and Nuclear Medicine.

Production and hosting by Elsevier

0378-603X � 2014 Production and hosting by Elsevier B.V. on behalf of Egyptian Society of Radiology and Nuclear Medicine.

http://dx.doi.org/10.1016/j.ejrnm.2014.03.007

Please cite this article in press as: Mansour S. et al., Comparative study between breast tomosynthesis and classic digital mammographevaluation of different breast lesions, Egypt J Radiol Nucl Med (2014), http://dx.doi.org/10.1016/j.ejrnm.2014.03.007

Sahar Mansoura,d,*, Lamia Adel

a,d, Omina Mokhtar

b,d, Omar Sherif Omar

c,d

a Radiology Department (Women’s Imaging Unit), Faculty of Medicine, Cairo University, Egyptb Radiology Department (Women’s Imaging Unit), National Cancer Institute of Cairo, Egyptc Surgery Department (Breast Specialist), Faculty of Medicine, Cairo University, Egyptd Wadi El-Neel Hospital, Radiology Department, Breast Imaging Unit Incorporation with Institute Gustave-Roussy (IGR),Dusseldorf Breast Cancer Center, Helsinki Breast Cancer Center and Institute Curie, Saint Cloud, France

Received 19 February 2014; accepted 14 March 2014

Available online xxxx

KEYWORDS

Breast;

Digital mammography;

Biopsy;

Computer applications-3D;

Calcifications

Abstract Objective: To evaluate the impact of adding 3D Tomosynthesis to Full Field Digital

Mammography (FFDM) in the detection and diagnosis of breast lesions.

Subjects and methods: The study included 166 mammograms with indeterminate findings selected

from 1600 mammograms. They were classified into two groups: group 1 ‘Diagnostic mammograms’

of symptomatic women and group 2 ‘Screening mammograms’. Dense breasts assigned as ACR3 and

ACR4 presented 69% (n= 114/166) of the studied cases. FFDMand 3D tomosynthesis examination

was done and imaging findings were evaluated before and after the use of 3D tomosynthesis

images.

Results: Both modalities were compared regarding detection and diagnosis, each individually

assessed, using the Pearson Chi Square tests. Detection (P value: 0.006) and diagnosis (P value:

0.048) of breast lesions dramatically improved when 3D tomosynthesis images were considered in

the evaluation. The sensitivity, specificity, and accuracy of digital mammography was 60%,

20.7% and 48% have significantly enhanced on applying tomosynthesis to be 94.5%, 74% and

89.7%.

Conclusion: Three-dimensional tomosynthesis significantly enhanced the detection and character-

ization of breast lesions on digital mammography especially in the context of dense breast paren-

chyma (ACR 3&4).� 2014 Production and hosting by Elsevier B.V. on behalf of Egyptian Society of Radiology and Nuclear

Medicine.

y in the

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1. Introduction

Mammography is an effective imaging tool for the detection ofearly-stage breast cancer, and it is the only screening modality

proved to reduce mortality from breast cancer (1–3). However,the appearance of overlapping tissue on mammograms poses asignificant obstacle to interpretation (4–7).

Breast tomosynthesis is anew tool that canbe expected toame-liorate this problem by reducing or eliminating tissue overlap (8).

The purpose of this study is to evaluate the potential impactof adding 3D Tomosynthesis to Full Field Digital Mammogra-

phy on the detection and diagnosis of breast lesions.

2. Material and methods

This study is a prospective analysis approved by the EthicsCommittee inWadi El-Neel Hospital, where radiological exam-ination of the study cases had been performed in a well

equipped and organized breast imaging unit incorporation withInstitute Gustave-Roussy (IGR), the leading European anti-cancer center. Included cases have given informed consents.

2.1. Material

The study included 166 consecutive mammograms with posi-

tive findings on the standard mammography examination.Studies were performed during the period of 13 months.Included cases were classified into two groups according to

the objective of their referral: Group 1: ‘Diagnostic mammo-grams’ of symptomatic women. Group 2: ‘Screening mammo-grams’ of non symptomatic women referred for their regularannual check up.

2.2. Methods

2.2.1. Mammography examination

A combined FFDM and 3D tomosynthesis examination wasdone by Hologic Selenia Dimensions Digital Tomosynthesis

System using the following steps:

� Position views: Images are taken both in the cranio-caudal(CC) and medio-lateral oblique (MLO) views.

� Acquisition: The system attains a ‘‘Combo-mode’’ imagingtechnique (2D + 3D imaging) that acquires a traditionaldigital mammogram and a tomosynthesis scan in the same

compression. During a tomosynthesis scan, multiple (11–15), low-dose images of the breast are acquired at differentangles while the X-ray tube moves in an arc across the

breast. These images are then used to produce a series ofone-millimeter thick images (from 60 to 90 slices) that canbe reconstructed to a three dimensional image of the breast.

� Displaymethodology: Images are displayed on dedicated highresolution workstations with special capabilities that are tai-lored for breast imaging. The re-constructed tomosynthesisimages can be viewed as one slice at a time or in a cine loop.

2.2.2. Ultrasound examination

A complementary ultrasound examination was performed forall cases using both B-mode and elastography ultrasound on

Please cite this article in press as: Mansour S. et al., Comparative study bevaluation of different breast lesions, Egypt J Radiol Nucl Med (2014), ht

Aplio XG device (Toshiba, Japan) to confirm or exclude mam-mography identified abnormalities. Examination was done by6–9 MHz high frequency probes.

2.3. Image analysis

According to the ‘‘Breast Imaging Data and Reporting

System’’ (9) mammograms of all patients were assigned an ini-tial BIRADS category in view of their Full Field Digital mam-mography (FFDM) findings by two independent readers (A.L.

and M.S. of 18 and 15 years experience) into: (i) BIRADS 3 orBIRADS 4 mammograms: with indeterminate benign ormalignant mammography findings, (ii) BIRADS 1 and BIR-

ADS 2 mammograms: if the tomosynthesis images addednew undetected lesions in BIRADS 1 or changed the categoryof detected ones in BIRADS 2 and (iii) BIRADS 5 cases: whenadditional findings were reported on reviewing the tomosyn-

thesis images (e.g. additional undetected lesions or widertumor extent).

A second look of the mammograms established by another

individual reader (M.O. of 20 years experience) and anotherBIRADS category assigned after a combined review of boththe tomosynthesis and the regular digital mammography

images.The authors were blinded regarding the image analysis per-

formed by each of them and both the initial mammogram(only regular mammogram) and re-evaluation (combined

tomosynthesis and regular mammography images) were per-formed without knowledge of the pathology results. At thestage of final evaluation, there was multidisciplinary discussion

of findings with the authors and the breast surgery consultant(O.O.).

On reporting the mammogram, we answered the following

questions before and after evaluating the 3D tomosynthesisimages:

1. Can we detect any abnormality? (mass lesions, parenchymaldistortion, focal asymmetries, micro calcifications or diffusebreast edema pattern).

2. Can we characterize/ diagnose this abnormality? (i.e. classify

as benign, indeterminate or malignant).3. Which BIRADS category could we assign?

4. Should we recommend or deter further biopsy?

5. Does the FFDM findings whether or not combined with 3D

tomosynthesis concomitant with the pathology results?

6. Do we need a follow up study for confirming the current

mammography findings?

Ultrasound guided core biopsy using a 14G biopsy needlewas performed in 63% (n= 104) for malignant looking (BI-

RADS 5), suspicious (BI-RADS 4) and indeterminate lesions(BI-RADS 3). The remaining BI-RADS 3 category (n= 26)and BI-RADS 2 category (n = 35) lesions were managed

according to the ACR guideline which is determined duringthe follow up: a one year stable lesion was considered ofbenign nature.

2.4. Statistical analysis

Imaging findings were tabulated and categorical results of Full

Field Digital Mammography and 3D Digital Tomosynthesis

etween breast tomosynthesis and classic digital mammography in thetp://dx.doi.org/10.1016/j.ejrnm.2014.03.007

Fig. 1 Tiny carcinoma that could be only identified on the tomosynthesis images (circle in B).

Impact of three dimensional tomosynthesis 3

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were included. Both modalities were compared in the contextof detection and diagnosis, each was individually assessed,using the Pearson Chi Square tests. The sensitivity, specificity,

accuracy and positive and negative predictive values of eithermodality were also calculated. P value <0.05 is consideredto be significant.

3. Results

The study included two groups of patients. Group 1 patients

(94 cases, 56.4%) were symptomatic cases. Group 2 patients(72 cases, 43%) were asymptomatic ones coming for their reg-ular annual check-up (Fig. 1).

Increased breast density significantly affected the diagnostic

ability of mammography. Such cases were misinterpreted inmammograms and were assigned with breast densities ofACR3 (48.2%, n = 80/166), and ACR4 (20.5%, n= 34/166).

The capability of FFDM and 3D tomosynthesis in thedetection of breast pathologies was simplified in Table 1.Tomosynthesis significantly enhanced the detection of the

breast lesions on mammography images especially in the con-text of dense breast parenchyma (P value: 0.006) (Fig. 2). Thedetection of multicentric lesions was also accessible in thetomosynthesis images (Fig. 3).

Using of tomosynthesis slices also significantly helped inbetter lesions characterization and consequently verifiedbenign or malignant impression of the identified masses (P

value: 0.048) (Table 2, Fig. 4). Based on tomosynthesis images,tumor margins were better assessed (n= 101). Also clusters ofmicrocalcifications (n = 66) were better identified (Fig. 4b)

especially in dense breasts.

Table 1 Comparison between the detection capability of

FFDM before and after 3D tomosynthesis imaging application

in the assessment of breast lesions.

Mammography detection Tomosynthesis detection Total

Yes No

Yes 125 (75.3%) 3 (1.8%) 128 (77.1%)

No 33 (19.9%) 5 (3.0%) 38 (22.9%)

Total 158 (95.2%) 8 (4.8%) 166 (100%)

Please cite this article in press as: Mansour S. et al., Comparative study bevaluation of different breast lesions, Egypt J Radiol Nucl Med (2014), ht

All mammograms were assigned an initial BI-RADS cate-gory, then the 3D tomosynthesis images were re-viewed andthe BIRADS score was re-adjusted by being either upgraded,

downgraded or remained unchanged (Table 3).Adding the 3D tomosynthesis images to the regular mam-

mography significantly enhanced accurate BIRADS scoring(P value: 0.00). In reference to Table 3 we can deduce the

following:

� Three-dimensional tomosynthesis images significantly

decreased the number of indeterminate/suspicious lesions,(BIRADS 3 & 4) by either supporting a benign (downgrad-ing) or a malignant (upgrading) diagnosis.

� In BI-RADS 5 (28.9%, n = 48) cases, 3D tomosynthesisshowed more accurate tumor extension and allowed betterprediction of subtle microcalcific clusters especially in dense

breast parenchyma (Fig. 5).� Pathologically proved BIRADS 6 lesions (3%, n= 5) thatwere under neoadjuvant chemotherapy could not be identi-fied on mammography. Tomosynthesis allowed better

depiction of such pathologies by providing the possibilityof recognizing post therapy residual tumor tissue (Fig. 6).� Tomosynthesis did not only allow a more confident malig-

nant diagnosis of some mass lesions but it helped in con-firming the benign nature of BIRADS 2 (31.3%, n = 52)lesions as well. The presence of well defined margins, the

typical benign radiolucent halo and the intra-lesional fatdensity verified the benign diagnosis of these lesions.� Operative bed recurrence could be excluded from extensivescars (4.8%, n = 8). In such cases, no recurrent masses were

identified in any of the tomosynthesis slices and moreover infive cases, associated central fat density could be elicitedwhich further excluded tumor recurrence (Fig. 7).

Recommendation of biopsy for detected lesions was basedon the combined evaluation of FFDM, 3D tomosynthesis

and ultrasound examinations (Table 4). Revision of pathologyspecimens revealed 77 malignant lesions (46.4%) and 89benign lesions (53.6%). Ten cases (6%) of those benign lesions

were found to be precancerous. With the aid of tomosynthesisslices, 62 cases (37.3%) were saved from unnecessary biopsy.

The sensitivity, specificity, and positive and negative predic-tive values of FFDM when assessed individually and when

combined with 3D tomosynthesis were illustrated in Table 5.

etween breast tomosynthesis and classic digital mammography in thetp://dx.doi.org/10.1016/j.ejrnm.2014.03.007

Fig. 2 Left breast large invasive duct carcinoma that is hardly seen on the FFDM images (A). It was assigned as BIRADS 4. The

carcinoma appears more evident on the tomosynthesis slice (B) and was upgraded to BIRADS 5. Complementary ultrasound (C)

confirmed the tomosynthesis findings.

4 S. Mansour et al.

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False negative tomosynthesis results included six benignbreast lesions in heterogeneous breast parenchyma and onecase of duct carcinoma in situ (DCIS) in an ACR4 breast.

False positive results included two cases of granulomatousmastitis, four benign precancerous lesions, one case ofpost operative fat necrosis and three cases with atypical

fibroadenomas.

4. Discussion

Breast tomosynthesis is considered one of the most challengingand promising up to date mammography technologies. Tomo-synthesis is expected to resolve mammography drawbacks by

eliminating tissue overlap due to its ability to acquire 3Dimages of the breast (8).

A number of investigators believe that 3D tomosynthesis

has a potential impact in both screening and diagnostic

Please cite this article in press as: Mansour S. et al., Comparative study bevaluation of different breast lesions, Egypt J Radiol Nucl Med (2014), ht

settings. The use of tomosynthesis could alter the diagnosticprotocol substantially (10).

Several studies had considered breast tomosynthesis an

entrance for a 3D imaging capability that allows more accurateevaluation of lesions by enabling better differentiation betweenoverlapping tissues (8,11–14). Most of the articles reviewed its

role literally. There was a paucity of references that had dis-cussed its use in routine clinical practice.

A prospective study (12), examined the effect on radiogra-

phers’ and radiologists’ workload when implementing 3Dmammography in screening by comparing image acquisitiontime and screen-reading time for 2D mammography with thatof combined 2D+ 3D mammography.

The main issue of their study focused upon time consumedversus accuracy in interpretation of the mammograms of theselected cases. They found out that combined 2D + 3D mam-

mography prolongs image acquisition time and screen-reading

etween breast tomosynthesis and classic digital mammography in thetp://dx.doi.org/10.1016/j.ejrnm.2014.03.007

Fig. 3 Screening mammogram showed a subtle mid upper breast area of parenchymal distortion that became more apparent on one of

the tomosynthesis slices in addition to another lesion (arrows). Complementary ultrasound proved the presence of an underlying two tiny

spiculated mass lesions.

Table 2 Comparison between the diagnostic ability of FFDM

before and after combining the 3D tomosynthesis imaging in

the assessment of breast lesions.

Mammography diagnosis Tomosynthesis diagnosis Total

Yes No

Yes 51 (30.7%) 4 (2.4%) 55 (33.1%)

No 90 (54.2%) 21 (12.7%) 111 (66.9%)

Total 141 (84.9%) 25 (15.1%) 166 (100%)

Impact of three dimensional tomosynthesis 5

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time (at initial implementation), yet appears to be associatedwith improved screening accuracy, which consequently help

in detection of more cancers (12).Skaane et al. compared digital mammography and digital

breast tomosynthesis (DBT) in a side-by-side feature analysis

for cancer conspicuity, and assessed whether there is a poten-tial additional value of DBT to standard conventional imagingregarding the detection of additional malignancies. The study

included 129 women and actually biopsied 45 breasts (theremaining 84 cases were dismissed with a normal/definitelybenign finding that presented no need for biopsy). Accordingto their work; the side-by-side feature analysis showed higher

conspicuity scores for tomosynthesis compared to conven-tional 2D for cancers presenting as spiculated masses and dis-tortions (15).

Hakim et al. (10) subjectively compared additional mam-mographic views to DBT when characterizing known masses,architectural distortions, or asymmetries. The study considered

mammography of 25 women with known masses. After reviewof the examinations, radiologists rated their relative preferencein terms of classifying the finding in question twice; one timewhen aided by the additional views and another when aided

by DBT. The diagnostic BI-RADS rating of both examina-tions was correlated. They found that FFDM and DBT(combined) were perceived to be better for diagnosis in 50%

of cases. Finally they concluded that DBT may be an alterna-tive to obtaining additional mammographic views in most

Please cite this article in press as: Mansour S. et al., Comparative study bevaluation of different breast lesions, Egypt J Radiol Nucl Med (2014), ht

cases especially if the presentation of the concerned lesion isnot by calcification.

During our experience; the 3D tomosynthesis images hadincreased the sensitivity and accuracy of mammography and

significantly enhanced accurate BIRADS scoring (P value:0.00). The proved malignant lesions (n= 77) were correctlydiagnosed by mammography in 14 cases (18.1%), such estima-

tion became more accurate when 3D tomosynthesis included inthe evaluation to be 48 cases (62.3%). Even when malignantmass lesions were identified on mammograms, 3D tomosyn-

thesis still has a role in defining actual tumor size and exten-sion (Fig. 5). We have to admit that the diagnostic accuracypercentage for FFDM was very low to be accepted on a stan-

dard basis; yet it is a unique situation in this study as most ofthe malignant cases were of dense breast categories.

Tomosynthesis significantly enhanced the cancer detectionrate of mammography as it showed a sensitivity of 94.5% com-

pared to only 60% in solo mammography evaluation. This wascoupled with its impact on the diagnostic accuracy of mam-mography that had upgraded from 48% to 89.7%. Improved

depiction of clustered microcalcifications, together with bettermargin delineation and superior resolution has paved way formaking an accurate diagnosis (Fig. 4b).

In a study done in 2012, DBT was compared with mammo-graphic spot views (MSVs) in characterizing 67 breast massesas benign (n = 37) or malignant (n = 30). In this small-samplestudy, mass characterization in terms of visibility ratings,

reader performance, and BI-RADS assessment with DBTwas similar to that with MSVs. Preliminary findings suggestthat MSV might not be necessary for mass characterization

when performing DBT (16).From our point of view, tomosynthesis being a ‘‘slice fold-

ing’’ technique has only the capability to locate the site of cal-

cific clusters but not to accurately suggest the possiblepathology of clusters. Regarding this issue spot magnificationview is a better method of evaluation.

Kontos et al. in 2011 presented a correlation between theparenchymal texture features at DBT and digital mammogra-phy with breast percent density (PD) in a screening population

etween breast tomosynthesis and classic digital mammography in thetp://dx.doi.org/10.1016/j.ejrnm.2014.03.007

Fig. 4 Two different cases showing diffuse non specific edema

pattern of the right breast with coarsened trabeculae, increased

breast density and diffuse skin thickening. Case1 (A) is granu-

lomatous mastitis. Tomosynthesis images added no information.

Case 2 (B) is an extensive invasive duct carcinoma. Malignant

microcalcific clusters and spiculations are excellently demon-

strated on the tomosynthesis image.

Table 3 Comparison between the initial mammography BI-RAD

tomosynthesis images.

Mammography BI-RADS Tomosynthesis BI-RADS

1 2 3

1 4 14 3

2 3 11 1

3 9 22 9

4 2 5 2

5 0 0 0

6 0 0 0

Total 18 52 1

Fig. 5 A typical carcinoma that is easily identified on the CC

view of a FFDM examination, yet, wider extension could be

depicted on the tomosynthesis slice.

6 S. Mansour et al.

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Please cite this article in press as: Mansour S. et al., Comparative study bevaluation of different breast lesions, Egypt J Radiol Nucl Med (2014), ht

of women. According to their study, parenchymal texture fea-tures are more strongly correlated to breast PD in DBT than in

digital mammography. The authors’ long-term hypothesis isthat parenchymal texture analysis with DBT will result inquantitative imaging biomarkers that can improve the estima-

tion of breast cancer risk (17).The current work included 114 (69%) cases with dense

parenchymal texture (i.e. ACR 3 and 4). Lesions in dense

breast parenchyma were sometimes upgraded or downgradedon the tomosynthesis images; a fact which had a major impactin the perspective of recall rates in screening mammographyand in the perspective of biopsy referral in the diagnostic con-

text. It allowed a more confident diagnosis of both benign andmalignant pathologies.

Breast abnormalities were more depicted at 3D-tomosyn-

thesis that detected 158 out of the 166 studied lesions(95.2%) and missed only eight lesions (4.8%), while on theother side digital mammography had missed 38 lesions

(22.9%). Also the interpretation of the abnormality was betterdefined by tomosynthesis which characterized and properlydiagnosed 141 lesions (84.9%) while digital mammography

hit the target in only 55 lesions (33.1%).

S scoring and the re-adjusted score after re-viewing the 3D

Total

4 5 6

1 0 0 22

5 2 0 22

4 3 0 47

18 29 0 56

0 14 0 14

0 0 5 5

5 28 48 5 166

etween breast tomosynthesis and classic digital mammography in thetp://dx.doi.org/10.1016/j.ejrnm.2014.03.007

Fig. 6 Proved carcinoma under neo-adjuvant chemotherapy. Tumor is in-apparent on FFDM image (A). It becomes clearly illustrated

on the tomosynthesis images (arrow in B).

Fig. 7 A 37-year-old female with history of right conservative

breast surgery. She recently noticed a palpable operative bed

lump. Her mammogram showed operative bed microcalcifications

and spiculations. She was assigned BI-RADS 4 score with

suspicious recurrence. Tomosynthesis images showed a central

radio-lucency with fine egg shell calcifications; a picture that is

typical for operative bed fat necrosis. She was downgraded to BI-

RADS 2 score.

Table 4 Number of performed breast biopsies and results of

revision of pathology specimens.

Pathology Total No.

of cases

Biopsy

performed

Biopsy

deterred

Benign 79 (47.6%) 17 62

Fibroadenomas 5 1

Mammary dysplasia 2 –

Fibrocystic changes 2 25

Mastitis 6 1

Normal 2 9

Scar 8

Duct ectasia 2

Precancerous 10 (6%) 10 –

Malignant 77 (46.4%) 77 –

DCIS 6

Lobular carcinoma 3

Malignant phylloids 1

Invasive duct carcinoma 67

Total 166 104 62

Table 5 Calculated sensitivity, specificity, accuracy, and

positive and negative predictive values of FFDM before and

after combining the 3D tomosynthesis in the assessment of

breast lesions.

Statistics Mammography (%) Tomosynthesis (%)

Sensitivity 60 94.5

Specificity 20.7 74

Accuracy 48 89.7

Positive predictive value 62 92

Negative predictive value 20 80

Impact of three dimensional tomosynthesis 7

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Nevertheless we have to admit that breast tomosynthesissometimes does not save the case, it holds the challenge of‘‘absence of mass effect’’. Lesions with no associate architec-

tural compression and/or distortion may be indiscernible fromthe related parenchyma in breast with ACR 3&4 categories(Fig. 8). Such condition may present with a number of consid-

ered pathologies such as: Intraductal epithelial hyperplasia,lobular carcinoma in situ and ductal carcinoma in situ (DCIS).Presence of an area of abnormal echo pattern on complemen-tary breast US could draw attention to biopsy and conse-

quently solve such problem.

Please cite this article in press as: Mansour S. et al., Comparative study bevaluation of different breast lesions, Egypt J Radiol Nucl Med (2014), ht

Bernardi et al. (12), in 2012 stated that there is limited evi-dence on the role of 3D mammography with tomosynthesis in

breast screening, although early studies suggest that it mayimprove specificity. They evaluated the effect of integrating3D mammography on 158 consecutive recalls to assessment

in asymptomatic subjects and finally found out that their study

etween breast tomosynthesis and classic digital mammography in thetp://dx.doi.org/10.1016/j.ejrnm.2014.03.007

Fig. 8 Patient is 58 years old with history of right breast cancer post mastectomy. One year post therapy follow-up revealed contralateral

ductal carcinoma in situ (DCIS) solid and cribriform patterns with stromal microinvasion. (A) Left-sided FFDM and tomosynthesis MLO

and CC views show unremarkable findings. (B) Color Doppler US shows ill-defined area of abnormal hypoechoic texture. Note small

feeding vessel targeting the lesion. According to the mammography the breast is BI-RADS 1 yet US displays BI-RADS 4a which is the

nearer category to the pathology results.

8 S. Mansour et al.

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clearly demonstrates the capability of 3D tomosynthesis toimprove breast screening specificity and reduce recall rates.

Another experience (18) compared the image quality oftomosynthesis with that of conventional mammography andestimated the recall rate of screeningwhen tomosynthesis is used

in addition to mammography. There were 99 digital screeningrecalls in 98 women. They stated that the image quality of tomo-synthesis was equivalent (n= 51) or even superior (n = 37) to

diagnostic mammography in 89% (88/99). Finding type was sig-nificantly (P < 0.001) associated with equivalence. Approxi-mately half – 52/99 (52%) – of the findings would not havebeen recalled when digital screeningmammography was supple-

mented with tomosynthesis. When adjusting for confoundingconditions, the recall reductionwas 40% (37/92). The likelihoodof recall was also dependent on finding type (P = 0.004).

Our work limited by the fact that it was carried out in anon-screening institute; most of the patients present withwell-established breast pathology and needed diagnostic mam-

mogram. Some of the cases had complaints regarding otherbody system and were sent for check up, in other words sentfor Screening mammograms to exclude additional breastdisease. Such condition markedly limited recall/assessment

option.From our experience we could recommend breast cancer

screening scheme as follows: First, start the screening imagewith

3D tomosynthesis ‘‘Combo-mode’’ imaging technique using theCC views. If there was any impression of hidden pathology thenit is better to continue with 3D tomosynthesis technique. If no

abnormality was detected then instead do the MLO views withthe regular FFDM.Women with dense breasts, even with nega-tive mammograms (i.e. BI-RADS 1) need additional breast

ultrasound examination to exclude malignancy.

5. Conclusion

Three-dimensional tomosynthesis significantly enhances thedetection and characterization of breast lesions on digital

Please cite this article in press as: Mansour S. et al., Comparative study bevaluation of different breast lesions, Egypt J Radiol Nucl Med (2014), ht

mammography especially in the context of dense breast paren-chyma (ACR 3&4).

Authors’ contribution

Study concepts: O.M., L.A. and O.O.Study design: S.M.

Data acquisition: S.M. and O.M.Quality control of data and algorithms: S.M.Data analysis and interpretation: S.M., L.A. and O.M.

Statistical analysis: S.M.Manuscript preparation: S.M.Manuscript editing: S.M.

Manuscript review: S.M., O.O.

Sources of support

Wadi El-Neel Hospital.

Conflicting interest

The authors declare that they have no conflict of interests.

Acknowledgment

The authors do thank Prof. Dr. Rasha Kamal for her help withthe statistical analysis and prof. Dr. Hassan ElKiki, Head of

the Radiology Department, Wadi El-Neel Hospital for his sup-port in supplying methods of examination.

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Impact of three dimensional tomosynthesis 9

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